Coding Cues

February 2, 2007

Answers to your questions about...new or established patients; modifiers with injection codes; "per day" E&M services

New or established patients

You should report an established patient office visit (99212-99215) if you see the patient within three years of the hospital encounter. This is the case whether the patient is commercially insured or covered by Medicare. According to CPT, "an established patient is one who received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." Medicare defines "professional services" as an E&M service or other face-to-face service. So, since you provided this type of service to the patient, you'd consider him established if you see him again within 36 months.

For instance, say you, an FP, see a patient in the hospital and recommended that he follow up with a gastroenterologist in your group. In this case, you could use the appropriate new patient code (99201-99205) for the patient's visit to the gastroenterologist.

Modifiers with injection codes

I performed an E&M service for a 62-year-old patient with a URI. Based on the history, exam, and medical decision-making, I decided to give her a penicillin injection. Should I append modifier –25 to the office visit code?

Yes. You'd attach the modifier when you perform a significant, separately identifiable E&M service in addition to the injection. For the injection administration code, use 90772 (therapeutic, prophylactic or diagnostic injection . . . ).

Link both the office visit and the injection code to the URI diagnosis, such as 465.8 (acute upper respiratory infections . . .).

Also report the appropriate J code for the penicillin. Be sure to bill for all the units you inject.

"Per day" E&M services

An elderly patient fell off a ladder and came to the office at 5 p.m. that day complaining of leg pain. I saw him in the office again the next morning because he was still in pain. I know I won't be paid for two E&M visits billed on the same day for the same patient unless the visits are for unrelated problems. Because both services were in the same 24-hour period, should I combine both visits and submit just one code?

No. The prohibition involves a "day," not a "24-hour period." A day starts at midnight and ends at 11:59:59 p.m. So you can report a separate code for each of the two visits.

The same rules apply to inpatient E&M codes, as well. So if you perform an initial hospital visit for a patient at 10 p.m. and submit hospital admission code 99222, it's completely appropriate to see the same patient at 7:30 a.m. the next "day" and submit 99232 for subsequent hospital care.

This information is adapted from material provided by The Coding Institute. For a free sample issue or information on how to subscribe to any of 29 specialty-specific coding newsletters, please contact The Coding Institute, 2272 Airport Road South, Naples, FL 34112; phone 800-508-2582; fax 800-508-2592; or visit http://www.codinginstitute.com.